Schnock KO, Biggs B, Fladger A, et al. J Patient Saf. 2021;17:e462-e468.
Hospitals have implemented radiofrequency identification (RFID) technology to improve patient safety. This systematic review of 5 studies suggests that use of RFID can lead to rapid, accurate detection of retained surgical instruments (RSIs) and reduced risk of counting errors.
Abraham J, Pfeifer E, Doering M, et al. Anesth Analg. 2021;132:1563-1575.
Intraoperative handoffs between anesthesiologists are frequently necessary but are not without risk. This systematic review of 14 studies of intraoperative handoffs and handoff tools found that use of handoff tools has a positive impact on patient safety. Additional research is needed around design and implementation of tools, particularly the use of electronic health records to record handoffs.
Park Y, Hu J, Singh M, et al. JAMA Netw Open. 2021;4:e213909.
Machine learning uses data and statistical methods to enhance risk prediction models and it has been promoted as a tool to improve healthcare safety. Using Medicaid claims data for a large cohort of White and Black pregnant females, this study evaluated approaches to reduce bias in clinical prediction algorithms for postpartum depression and mental health service utilization. The researchers found that a reweighing method in machine learning models was associated with a greater reduction in bias than excluding race from the prediction models. The authors suggest further examination of potentially biased data informing clinical prediction models and consideration of other methods to mitigate bias.
Mahajan P, Pai C-W, Cosby KS, et al. Diagnosis (Berl). 2021;8:340-346.
Diagnostic error is an ongoing patient safety challenge that can result in patient harm. This literature review identified a set of emergency department (ED)-focused electronic health record (EHR) triggers (e.g., death following ED visit, change in treating service after admission, unscheduled return to the ED resulting in admission) and non-EHR based signals (e.g., patient complaints, referral to risk management) with the potential to screen ED visits for diagnostic safety events.
Handoffs are essential to communicating important information and preventing adverse patient care outcomes. This qualitative study explored how information about ICU patients’ family members is included in handovers. Findings suggest that written documentation about the family is inadequate and poorly structured and there is a need for user-friendly handoff tools that include information on patients’ family members.
This commentary presents two cases of near-miss wrong-patient order errors between mother-newborn pairs and discusses the unique threat the postpartum setting presents to electronic order safety. The article highlights opportunities for systems improvement.
Vanneman MW, Balakrishna A, Lang AL, et al. Anesth Analg. 2020;131:1217-1227.
Transfusion errors due to patient misidentification can have serious consequences. This article describes the implementation of an automated, electronic barcode scanner system to improve pretransfusion verification and documentation. Over two years, the system improved documentation compliance and averted transfusion of mismatched blood products in 20 patients.
Howlett MM, Butler E, Lavelle KM, et al. Appl Clin Inform. 2020;11.
Using a pre-post approach, this study assessed the impact of implementing electronic prescribing and smart pump-facilitated standard concentration infusions on medication errors in a pediatric intensive care unit (PICU). The overall error rates were similar before and after implementation but the error types changed before and after implementation of these tools. After implementation, lack of clarity, incomplete orders and wrong unit errors were reduced but dosing errors, altered orders and duplicate errors increased. Pre-implementation, 78% of errors were deemed preventable by electronic prescribing and smart-pumps; post-implementation 27% of errors were attributed to the technology and would not have occurred if the order was not electronically created or administered via the smart-pump.
Kandagatla P, Su W-TK, Adrianto I, et al. J Healthc Qual. 2021;43:101-109.
This study examined the association of inpatient harms (e.g., infections, medication-related harms) and 30-day readmissions through a retrospective analysis of adult surgical patients in a single heath system over a two year period. The authors found that the harms with the highest 30-day readmission rates were pressure ulcers (45%), central line-associated bloodstream infections (40%), Clostridium difficile infections (29%), international normalized ratio >5 for patients taking Warfarin (26%), and catheter-associated urinary tract infections. The authors also described the accuracy of a risk prediction model to identify high-risk patients for 30-day admissions.
Anderson JE, Ross AJ, Back J, et al. Int J Qual Health Care. 2020.
Using ethnographic methods and resilient healthcare principles (described as systems that anticipate future demands, respond to current demands, monitor for emergent problems and learn from results, both positive and negative), the researchers interviewed and observed staff in emergency departments (EDs) and geriatric wards in one teaching hospital in London to identify system vulnerabilities to target with quality improvement interventions. The observations and interviews revealed difficulties with discharge planning and information integration as priority areas.
Appelbaum N, Clarke J, Feather C, et al. BMJ Open. 2019;9:e032686.
While medication errors during paediatric resuscitation are considered common, little information about the processes that contribute to them has been gathered. This prospective observational study in a large English teaching hospital describes the incidence, nature and severity of medication errors made by 15 teams, each comprised of two doctors and two nurses, during simulated paediatric resuscitations. Clinically significant errors were made in 11 of the 15 cases, most due to discrepancies in drug ordering, preparation and administration. The authors recommend additional research into new approaches to protecting patients in paediatric emergency settings.
Bezemer J, Cope A, Korkiakangas T, et al. BMJ Qual Saf. 2017;26:583-587.
Increased use of video technology in the health care setting may represent an opportunity to improve patient safety. The authors introduce a framework for using video data in patient safety research, present insights from numerous studies, and outline opportunities for further study.
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